Arch Iranian Med 2007; 10 (2): 242 – 245 Case Report Liver Mass Due to Penetration of a Silent Duodenal Ulcer Mohammad-Hossein Somi MD•*, Mohammad-Kazem Tarzamni MD**, Sara Farhang MD*, Amir-Taher Eftekhaar-Sadat MD*** Liver penetration is a rare but serious complication of peptic ulcer disease. We report a 60-year- old man, without any serious risk factor for peptic ulcer, presented with mild abdominal discomfort, food-related vomiting and weight loss, and a mass in the left hepatic lobe, which was the result of a silent duodenal ulcer penetration. The diagnosis was based on histological examination of the endoscopicl biopsies. Archives of Iranian Medicine, Volume 10, Number 2, 2007: 242 – 245. Keywords: Liver abscess • penetration • silent duodenal ulcer Introduction Case Report eptic ulcer diseases (PUD), which are A 60-year-old male patient presented with a common diseases, can be complicated by one-year history of discomfort in the upper P inflammation, ulceration, or perforation. abdomen with a negative history of heartburn or The diagnosis is easier to make when a history of severe pain. The pain was aggravated by vomiting ulceration or acute characteristic pain in abdomen (related to food ingestion) since one month prior to is present. presentation. He had been loosing weight during In order of decreasing frequency, penetration that period, which was associated with evening occurs into the pancreas, gastrohepatic omentum, fever (up to 38.5ºC). The patient was not taking biliary tract, and liver.1 Penetration into the liver is any medication and his family history was a rare complication of PUD and may lead to severe unremarkable. complications such as upper gastro- The patient was admitted to a provincial intestinal (GI) hemorrhage or abscess formation.2 hospital, while his body temperature was 38.5ºC Fifteen cases of endoscopically and histologically and his heart rate was 105 beats/min. The follow- diagnosed liver penetration by PUD have been ing laboratory parameters were of note: white previously reported, two of which were presented blood cells count: 18.6 x 10¹² /L (89% neutrophils, with GI bleeding. 11% lymphocytes), hemoglobin: 13.3 g/dL, We present a 60-year-old man, on no hematocrit: 40%, total bilirubin: 1.6 mg/dL, and medication, who developed a silent duodenal ulcer direct bilirubin: 1.4 mg/dL. Blood urea, creatinine, penetrated into the liver. The diagnosis was made and sugar concentrations were within normal by histological examination of the endoscopicl ranges. Wright and Widal agglutination tests were biopsies. negative. Liver function tests were mildly altered: SGOT: 94 U/L, SGPT: 107 U/L, alkaline phosphatase: 395 U/L, and amylase: 255 U/L. Authors’ affiliations: *Department of Internal Medicine, Abdominal ultrasonography (Figure 1) showed **Department of Radiology, ***Department of Pathology, Imam Hospital, Tabriz University of Medical Sciences, Tabriz, Iran. a hypoechoic ill-defined mass (96 x 56 mm) in the •Corresponding author and reprints: Mohammad-Hossein Somi left lobe of the liver, with lower echo in the center, MD, Liver and Gastrointestinal Diseases Research Center (LGDRC), Imam Hospital, University Ave., Tabriz 5166614756, probably due to necrosis, and five echogen nodules Iran. (26 mm in greater diameter) in the left lobe. An Tel: +98-411-336-7473, Fax :+98-411-336-7499, abdominal computed tomography, which was E-mail: [email protected]. Accepted for publication: 29 November 2006 performed one week later, confirmed the findings. 242 Archives of Iranian Medicine, Volume 10, Number 2, April 2007 M. H. Somi, M. K. Tarzamni, S. Farhang, et al was carried out. There was a linear ulcer in the distal esophagus. The stomach was normal. A deep and necrotic ulcer at the anterior wall of the duodenum (about 1.5 cm in diameter) was revealed in the bulb, extending to the prepyloric region with irregular margins. Biopsies from proximal and distal parts of the ulcer were taken. Histological examination of the specimens revealed glycogenic acanthosis in the esophageal mucosa, duodenal ulceration, and normal-appear- ing hepatocytes attached to the ulcerated area, which showed nonspecific inflammation as well (Figure 3). Before receiving the histological report, due to the severe and continuous symptoms, the patient was operated with primary diagnosis of hepatic abscess (through a midline incision in the upper Figure 1. Longitudinal ultrasound scan showing abdomen). masses in the liver. The abscess was firmly adhered to the anterior The tomogram showed a low-density lesion (120 x wall of the duodenum and a healed ulcer scar was 80 mm) and a little fluid next to the liver also noted. Evaluation of the liver specimens (Figure 2). revealed reactive inflammatory changes and The characteristics of the lesions suggested granulation tissue. neoplastic lesions (e.g., hepatocellular carcinoma The patient received treatment for Helicobacter and metastasis) as the first differential diagnosis, or pylori eradication. Upper GI endoscopy and abscess with hemangiomas. The gall bladder, ultrasonography were repeated after 40 days. The pancreas, kidneys, and spleen were normal. ulcers were cured completely and the ultrasonic The patient was referred to our hospital for pattern was normal except for the hypoechoic further evaluation. He was ill and mildly pale, but lesion in the left hepatic lobe (8 mm) suggesting had no adenopathies. Regardless of a mild deep hemangiomas. Liver functional tests were tenderness without peritoneal sign in the upper repeated, which all were in normal ranges. abdomen, the physical examination was normal. Because of upper GI symptoms and to seek a Discussion probable neoplastic origin, a gastroduodenoscopy We reported a rare case of endoscopically and histologically proven liver penetration by a Figure 3. Endoscopic biopsy showing Figure 2. Tomogram; the ulcer penetrated to the granulation tissue adjusted to normal- liver (arrowed) and expanded to the right lobe. appearance hepatocytes (arrowed). Archives of Iranian Medicine, Volume 10, Number 2, April 2007 243 Liver mass due to penetration of a silent duodenal ulcer Table 1. Characteristics of the reported cases of peptic ulcer penetration to the liver. Epigastric Main clinical Endoscopic Source Age/Gender Location pain/Tenderness feature appearance Anterior wall of Kayacetin2 61/ Male — GI bleeding Giant ulcer gastric antrum Lesser curve of Jimenez-Perez3 61/Male Tenderness GI bleeding Ulcer with mass corpus Lesser curve of Sperber4 69/Male Tenderness GI bleeding Ulcer corpus Lesser curve of Park5 52/Male — GI bleeding Giant ulcer antrum Anterior wall of Padda6 78/Male — GI bleeding Mass without ulcer duodenal bulb Lesser curve of Goldman7 65/Male Tenderness Nausea, anemia Ulcer with mass stomach Anterior wall of Brullet8 89/Female Epigastric pain GI bleeding Ulcer with mass gastric antrum Posterior wall of Novacek9 33/Female Epigastric pain GI bleeding Ulcer duodenal bulb Lesser curve of Guerrieri10 53/Male — GI bleeding Ulcer antrum Anterior wall of Martinez-Onsurbe11 91/Female — GI bleeding Ulcer antrum Posterior wall of Castellano12 77/Male — GI bleeding Ulcer duodenal bulb posterior wall of Castellano12 70/ Male Epigastric pain GI bleeding Ulcer antrum Lesser curve of Matsuoka13 53/Male Tenderness GI bleeding Giant ulcer corpus Anterior wall of Mostbeck16 53/Male Epigastric pain — Ulcer duodenal bulb Anemia, weight Anterior wall of Present case 60/Male Epigastric pain Ulcer loss duodenal bulb duodenal ulcer. To date, only fifteen cases of almost all of the cases, and the local inflammation peptic ulcer penetration into the liver — diagnosed was considered to be the reason of the mild by endoscopic biopsy, have been reported.2 – 16 The elevation of liver function tests.10 available data about thirteen cases are summarized The diagnostic value of the liver function tests in Table 1. in cases of the ulcer penetrating into the liver The main clinical presentation in most of the seems to be very limited. Liver function tests, cases was severe GI bleeding; however, there was which were normal in all but two reported cases, no evidence of dominant GI bleeding in our case. did not lead to the diagnosis. 7, 10 Abdominal pain and/or tenderness was reported in Liver penetration by a peptic ulcer often about half of the cases, including the present necessitates operative management, but generally a subject. Most of these cases had gastric ulcers. good outcome is expected. Successful treatment The size of the ulcers ranged from 2.5 × 2 cm in without operation was achieved in only two of the diameter to 9 × 3 cm. Malignancy was suspected patients; one treated with histamine H2-receptor due to the ulcer ground and irregular margin. In antagonist and the other one with a proton pump our case, a smaller ulcer was the cause, and the inhibitor.2, 5 While all previously described patients operation was done primarily to rule out were managed by an operation, the operation was malignancy. indispensable in the present case because of severe The presence of liver tissue in the histological and continuous symptoms due to the liver abscess. examination of endoscopic biopsies led to the Unlike the other cases, lack of prior GI correct diagnosis in all the cases. None of them symptoms or history of peptic ulcer and absence of was clinically or radiologically recognized prior to bleeding or use of nonsteroidal antiinflammatory endoscopy. Unspecific inflammatory infiltration in drugs (NSAIDs) in our patient, led us to use the liver tissue was the most common report in ultrasonography, despite unremarkable liver 244 Archives of Iranian Medicine, Volume 10, Number 2, April 2007 M. H. Somi, M. K. Tarzamni, S. Farhang, et al function tests, as the first diagnostic tool. But the by a duodenal ulcer. Am J Gastroenterol. 1997; 92: diagnosis was in favor of malignant etiologies and, 352 – 354. 7 Goldman IS. Endoscopic diagnosis of hepatic penetration therefore, an upper GI endoscopy was done into a gastric ulcer. Am J Gastroenterol. 1988; 83: seeking a probable source.